Provider Demographics
NPI:1063449288
Name:NEUSTROM, MARK R (DO)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:R
Last Name:NEUSTROM
Suffix:
Gender:M
Credentials:DO
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Mailing Address - Street 1:8675 COLLEGE BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66210
Mailing Address - Country:US
Mailing Address - Phone:913-491-5501
Mailing Address - Fax:913-491-8901
Practice Address - Street 1:8675 COLLEGE BLVD STE 200
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66210
Practice Address - Country:US
Practice Address - Phone:913-491-5501
Practice Address - Fax:913-491-8901
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KS25074207K00000X
MO105826207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
E54975Medicare UPIN
KS6126038CMedicare ID - Type Unspecified
MO6126038DMedicare ID - Type Unspecified